Are your Patients Learning OPTIMALLY?
Applying Motor Learning Theory into Practice
By: Erica A. Pitsch, PT, MPT, DPT, NCS
We can all agree that patients that are motivated are much easier to work with. We also know that learning is important to recovery, but making that learning a new movement pattern into a habit can be extremely challenging. Recent theories in motor learning may be able to help therapists provide better, and in fact, optimal learning conditions, and as a result, recover.
Gabrielle Wulf and Rebecca Lewthwaitte have proposed OPTIMAL: Optimizing Performance Through Intrinsic Motivation and Attention for Learning 1,2. Though the research that forms the foundation of this theory is primarily based on persons without neurological deficits, the principles are extremely relevant when applied to patients with neurological deficits including stroke. The purpose of this review is to describe the OPTIMAL theory and provide examples of how the theory can be applied to rehabilitation.
The first component of OPTIMAL theory regards intrinsic motivation, which can be improved through enhanced expectancies and a sense of autonomy. Let’s take a look at these two in detail:
Enhanced expectancies. Wulf and Lewthwaitte 1,2 describe several ways to enhance expectancies. They include promoting positive self-efficacy, providing specific types of feedback, defining success liberally and modifying the perceived task difficulty. Though going into depth on these concepts is beyond the scope of this blog, I to at least provide an exposure to the concepts. To start, consider the concept of self-efficacy, or a person’s beliefs about their abilities to achieve a certain outcome. If we think we have a high likelihood of success, it’s more likely that we will attempt that activity and are more motivated to continue. Also, prior success gives a sense of confidence and can predict future success. It feels even better if we achieve success at an activity we thought was challenging. Our patients are no different, only now the skills they are trying to learn are functional tasks they could do normally before their stroke or other event. Even worse, their first attempts at the movement are likely to require a lot of physical assistance and, as a result, pretty discouraging. A systematic review in 2011 found that self-efficacy was associated with several outcome variables such as quality of life and depression 3 (Jones & Riazi, 2011). Though our patients come to us with varying pre-existing levels of self-efficacy, we may be able to modify it though improving their success rate.
What can therapists do to enhance our patients’ expectations of success? Give the right kind of feedback. In particular, feedback on successful trials favorably affects learning and self-efficacy 1,2. This can be challenging as our patients may have a movement problem we are trying to fix. To highlight their perception of their ability to perform the task, you want to highlight what the patient did right, not what they did wrong. Taken another way, if you tell them what not to do, be sure you also show them what to do instead. Problem is, the patient might not clearly understand what part of the movement you are trying to praise. In this case, have a helper video record the patient performing the movement on their phone. This way you can slow the movement down and show them what was right about it- a form of self-modeling feedback. Social- comparative feedback is another option that can be used when done appropriately. In prior experiments, participants were told that their performance was in the top 10% for their age- no matter what their performance actually was 1,2. Clearly, lying to our patients is not appropriate, but there are some ways in which this strategy can be employed clinically.
The following case is an example of how these principles can be applied. Consider a 65 year old patient who takes 20 seconds to complete a five times sit to stand. For community dwelling older adults, greater that 12 seconds is considered a fall risk4. In addition, the patient plops back into the chair three out of the five times. Clearly, “good job! That’s normal!” is not an appropriate response. You are going to give them facts that they are a fall risk, and certainly highlight this fact to Medicare. However, applying OPTMAL principles, you can also highlight the positive attributes of the test: that they landed softly 2/5 times! (feedback on correct trials, as well as “liberal definition of success”). The patient may not know why they plopped back into the chair, so on video or your demonstration you can show how keeping the center of gravity forward allowed for better control (self-modeling). For social comparison strategies, though their performance on this test was above the fall risk threshold of the five times sit to stand, difficulty with arising from a chair is such a prevalent problem that some standardized tests still provide points for using hands to stand! I also tell my patients that in my clinical experience, many of my patients who scored the same, make such good progress I set it as a short term goal. The trick is, the patient has to want to practice, which brings me to the second strategy for improving motivation:
Autonomy. If any group of adults were more lacking autonomy, it is our patients in our hospital, SNF, or rehab center. They are told they must ring the call light to get out of bed. They need help for the most basic of tasks such as going to the bathroom, getting dressed, and feeding themselves. Not only are they under a lot of stress from the hospitalization and the life-changing acute illness, but this lack of autonomy is also a cause of stress. This stress can also degrade learning. It has also been found that authoritative language can also degrade learning. Think about all the commands are patients are under- you must call the nurse to get up, you must take this medication at this time, you must lock your brakes. Of course we need to enforce safety precautions- even staff MUST wash their hands when entering and exiting a room. The good news is there are simple things we can do to give our patients just a little shred of autonomy. For example, allowing simple choices can make a difference. One study found that participants who got to choose the color of golf ball putted more accurately 1,2. Considering that the choice does not even have to be influential (color of ball does not really affect the inertial properties of the ball), the opportunities for choice are endless. You can also make all of the multiple choice options still beneficial and relevant- does the patient want to work on walking faster or negotiate obstacles? We know progression of difficulty is important- does the patient want to go with a larger, lighter, or farther away target? What clothes would they like to work on wearing? Avoiding authoritative language can be a bit more difficult. As one physician asked a patient who self-discontinued blood pressure and diabetes medications- “do you WANT do have another stroke?”. This highlights the importance of patient education so that our patients can make informed decisions.
The last component of the OPTIMAL theory1,2 is attention for learning. In particular, external focus of attention, or directing the attention to outside the body, tends to have more favorable effects on motor performance and learning for many populations and tasks. The results when this strategy is applied to stroke patients are less consistent 4-7 . One of the challenges in finding consistency is the significant variability with the type of task and what is focused on. In my experience, focusing externally tends to more efficiently elicit the movement I am trying to get the patient to perform. For example, when teaching a straight leg raise, if they are sluggish in bringing their leg off the bed, simply holding my hand above their leg and saying “kick my hand” results in a more brisk performance. Consider our sit to stand patient again. He was capable of sitting down properly, just not every time. How to highlight how to do it? “eccentrically contract your quads” – probably not. When given an unstable object to hold while sitting, like balancing a paper cup on a clip board, the only solution to the problem is to land softly!
Taken together, the OPTIMAL theory for motor learning has several components that have potential for benefiting patients in rehabilitation. Therapists can make a big impact on the patient’s success with performing a task through simple cues and opportunities for autonomy, which in turn can improve a patient’s self-efficacy and motivation.
To learn more about Erica Pitsch and her course, “Overcoming Challenges in Stroke Rehab,” click here!
- Wulf G, Lewthwaite R.Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychon Bull Rev. 2016 Oct;23(5):1382-1414.
- Lewthwaite R, Wulf G Optimizing motivation and attention for motor performance and learning.Curr Opin Psychol.2017 Aug;16:38-42.
- Jones F1, Riazi A. Self-efficacy and self-management after stroke: a systematic review Disabil Rehabil. 2011;33(10):797-810
- Lusardi MM, Fritz S, Middleton A, Allison L, Wingood M, Phillips E, Criss M, Verma S, Osborne J, Chui KK. Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Meta-analysis Using Post test Probability. J Geriatr Phys Ther. 2017 Jan/Mar;40(1):1-36
- Durham KF1, Sackley CM2, Wright CC1, Wing AM3, Edwards MG4, van Vliet P5. Attentional focusof feedback for improving performance of reach-to-grasp after stroke: a randomised crossover study Physiotherapy. 2014 Jun;100(2):108-15.
- Kal EC, van der Kamp J, Houdijk H, Groet E, van Bennekom CA, Scherder EJ. Stay Focused! The Effects of Internal and External Focus of Attentionon Movement Automaticity in Patients with Stroke.PLoS One. 2015 Aug 28;10(8):
- Kal E, Houdijk H, van der Kamp J, Verhoef M, Prosée R, Groet E, Winters M, van Bennekom C, Scherder E. Are the effects of internal focus instructions different from external focus instructions given during balance training in stroke patients? A double-blind randomized controlled trial. Clin Rehabi 2019 Feb;33(2):207-221.
- Sakurada T, Nakajima T, Morita M, Hirai M, Watanabe E. Improved motor performance in patients with acute stroke using the optimal individual attentional strategy.Sci Rep. 2017 Jan 17